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Cooke School New Student Referral Packet
PLEASE ALLOW AT LEAST 30 CALENDAR DAYS TO COMPLETE THE REFERRAL PROCESS
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* Indicates required question
Email
*
Your email
Student's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Date of Referral
*
MM
/
DD
/
YYYY
Desired Start Date
*
MM
/
DD
/
YYYY
Reason for Referral
*
New to District/Move-In
Change of Placement
Other:
Native Language of Student
*
Your answer
Student's Home Address (street address, city, zip code)
*
Your answer
Student's Resident School District
*
Your answer
Student Resides with:
*
Parent
Foster Parent
Group Home
Other:
Parent(s)/Guardian(s) Name(s)
*
Your answer
Parent/Guardian's Phone Number
*
Your answer
Current MET Date
*
MM
/
DD
/
YYYY
Last Annual IEP Date Held
*
MM
/
DD
/
YYYY
Student's Special Education Eligibility on Current MET
*
CI
SXI
EI
ASD
Cooke Program student is being referred to:
*
SCI
SXI
DD* (*if DD please also complete this form:
https://forms.gle/UBBpYPFUhoWfQ1jT7
)
If DD please indicate CI level:
MiCI
MoCI
SCI
Clear selection
Referring District
*
Your answer
Current School & Program
*
Your answer
Previous School School & Program (if applicable)
Your answer
Is Student Currently Attending School Program
*
Yes
No
If "No" Please Explain
Your answer
Name of Person & Position Initiating Referral
*
Your answer
Phone Number
*
Your answer
Referring Person's Email Address
*
Your answer
1. List any student health concerns.
*
Your answer
2. List any medications taken by the student.
*
Your answer
3. Is the student under any physician ordered restrictions? Please explain.
*
Your answer
4. Diet information (food consistency, assistance needed, allergies, etc,):
*
Your answer
5. Describe the student's communication abilities.
*
Your answer
6. What are the student's strengths?
*
Your answer
7. In what way is the student dependent?
*
Your answer
8. Describe any special skills or interest of the student you have observed.
*
Your answer
9. Have the student or their parent/guardian expressed any concerns regarding current or future education issues? Please explain.
*
Your answer
10. Describe any student behavior(s) that interfere with instruction, stigmatize or isolates the student or endangers the student or other people.
*
Your answer
11. Are there any issues regarding this student with which you are particularly concerned? If so, please explain.
*
Your answer
12. Please list all outside or private services (OT, PT, Psychologists, Social Worker, etc.)
*
Your answer
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